Ultrasound-Guided PEI & RFA

Percutaneous Ethanol Injection for Treatment of Cervical Lymph Node Metastases in Patients with Papillary Thyroid Carcinoma

The objective of this study was to evaluate the technique, efficacy, and side effects of percutaneous ethanol injection in patients with limited cervical nodal metastases from papillary thyroid carcinoma.

SUBJECTS AND METHODS. Fourteen patients who had undergone thyroidectomy for papillary thyroid carcinoma presented with limited nodal metastases (one to five involved nodes) in the neck between May 1993 and April 2000. All patients had received previous iodine-131 ablative therapy with a mean total dose per patient of 7,548 MBq. Ten of the patients either were considered poor surgical candidates or preferred not to have surgery, and all were unresponsive to iodine-131 therapy. Each metastatic lymph node was treated with percutaneous ethanol injection, and patients received both clinical and sonographic follow-up.

Twenty-nine metastatic lymph nodes in our 14 patients were injected. Mean sonographic follow-up was 18 months (range, from 2 months to 6 years 5 months). All treated lymph nodes decreased in volume from a mean of 492 mm3 before percutaneous ethanol injection to a mean volume of 76 mm3 at 1 year and 20 mm3 at 2 years after treatment. Six nodes were re-treated 2-12 months after initial percutaneous ethanol injection because of persistent flow on color Doppler sonography (n = 4), stable size (n = 1), or increased size (n = 1). Two patients developed four new metastatic nodes during the follow-up period that were amenable to percutaneous ethanol injection. Two patients developed innumerable metastatic nodes that precluded retreatment with percutaneous ethanol injection. No major complications occurred. All patients experienced long-term local control of metastatic lymph nodes treated by percutaneous ethanol injection. In 12 of 14 patients, percutaneous ethanol injection was successful in controlling all known metastatic adenopathy.

Sonographically guided percutaneous ethanol injection is a valuable treatment option for patients with limited cervical nodal metastases from papillary thyroid cancer who are not amenable to further surgical or radioiodine therapy.

Role of Thyroglobulin Measurement in Fine-Needle Aspiration Biopsies of Cervical Lymph Nodes in Patients with Differentiated Thyroid Cancer

The identification of metastatic neck lymph nodes in patients awaiting surgery for differentiated thyroid tumor permits their excision during thyroidectomy. In order to detect thyroid cancer lymphatic metastasis before surgery, we measured thyroglobulin (Tg) in the needle wash-out of fine-needle aspiration biopsy (FNAB). Ultrasoundguided FNAB on enlarged neck nodes was performed in 23 patients awaiting surgery for differentiated thyroid tumor (n = 33 lymph nodes), 47 patients previously thyroidectomized for thyroid tumor (n = 89 lymph nodes), and 60 patients without thyroid disease (n = 94 lymph nodes). Immediately after aspiration biopsy, the needle was rinsed with 1 mL of normal saline solution and Tg levels were measured on the needle wash-out (FNAB-Tg). FNAB-Tg levels were markedly elevated in metastatic lymph nodes both in patients awaiting thyroidectomy (metastatic vs. negative lymph nodes, mean ± SEM, 16,593 ± 7,050 ng/mL vs. 4.91 ± 1.61 ng/mL; p < 0.001) and in thyroidectomized patients (11,541 ± 7,283 ng/mL vs. 0.45 ± 0.07 ng/mL; p < 0.001). FNAB-Tg sensitivity, evaluated through histological examination in 69 lymph nodes, was 84.0%. The combination of cytology plus FNAB-Tg increased FNAB sensitivity from 76% to 92.0%. In conclusion, FNAB-Tg measurement is a useful technique for early diagnosis of lymph node metastasis originating from differentiated thyroid cancer.

Diagnostic Utility of Thyroglobulin Detection in Fine-Needle Aspiration of Cervical Cystic Metastatic Lymph Nodes from Papillary Thyroid Cancer with Negative Cytology

Radiofrequency Ablation and Percutaneous Ethanol Injection
Treatment for Recurrent Local and Distant Well-Differentiated Thyroid Carcinoma

Objective: To assess the long-term efficacy of radiofrequency ablation (RFA) and percutaneous ethanol (EtOH) injection treatment of local recurrence or focal distant metastases of well-differentiated thyroid cancer (WTC).

Background: RFA and EtOH injection techniques are new minimally invasive surgical alternatives for treatment of recurrent WTC. We report our experience

and long-term follow-up results using RFA or EtOH

ablation in treating local recurrence and distant focal

metastases from WTC.

Methods: Twenty patients underwent treatment of

biopsy-proven recurrent WTC in the neck. Sixteen of

these patients had lesions treated by ultrasound-guided

RFA (mean size, 17.0 mm; range, 8–40 mm), while 6

had ultrasound-guided EtOH injection treatment (mean

size, 11.4 mm; range, 6–15 mm). Four patients

underwent RFA treatment of focal distant metastases

from WTC. Three of these patients had CT-guided RFA

of bone metastases (mean size, 40.0 mm; range, 30–60

mm), and 1 patient underwent RFA for a solitary lung

metastasis (size, 27 mm). Patients were then followed

with routine ultrasound, 131I whole body scan, and/or

serum thyroglobulin levels for recurrence at the

treatment site.

Results: No recurrent disease was detected at the

treatment site in 14 of the 16 patients treated with RFA

and in all 6 patients treated with EtOH injection at a

mean follow-up of 40.7 and 18.7 months, respectively.

Two of the 3 patients treated for bone metastases are

free of disease at the treatment site at 44 and 53

months of follow-up, respectively. The patient who

underwent RFA for a solitary lung metastasis is free of

disease at the treatment site at 10 months of follow-up.

No complications were experienced in the group treated

by EtOH injection, while 1 minor skin burn and 1

permanent vocal cord paralysis occurred in the RFA

treatment group.

Conclusions: RFA and EtOH ablation show promise as

alternatives to surgical treatment of recurrent WTC in

patients with difficult reoperations. Further long-term

follow-up studies are necessary to determine the

precise role these therapies should play in the

treatment of recurrent WTC.


Surgical alternative parathyroid cysts

Surgical alternative mixed thyroid cysts

Roberto Valcavi1, Andrea Frasoldati1 THYROID CYSTIC NODULES

1 Endocrine Unit, Arcispedale Santa Maria Nuova, Reggio Emilia, Italy

Objective: To provide an overview of ultrasound (US)-guided percutaneous

ethanol injection (PEI) therapy for thyroid cystic nodules and discuss the

practical and technical details.

Methods: We present preliminary data of a controlled randomized study

involving 281 patients (221 women and 60 men; 18 to 85 years old) with

benign thyroid cystic nodules. Study inclusion criteria were local discomfort

or cosmetic damage, cystic volume more than 2 mL, 50% or more

fluid component, benignity as confirmed by cytologic specimen obtained

by US-guided fine-needle aspiration biopsy (FNAB), and euthyroidism.

Exclusion criteria were inadequate, suspicious, or positive FNAB cytology,

high serum calcitonin, and contralateral laryngeal cord palsy. By random

assignment, 138 patients underwent simple cyst evacuation, and 143

underwent cyst evacuation plus PEI by a skilled operator using a US-guided

technique. The amount of ethanol injected was 50 to 70% of the cystic fluid extracted.

Results: Before treatment, the mean (±SD) nodule volume was 19.0 ± 19.0 mL

versus 20.0 ± 13.4 mL in the PEI versus the simple evacuation group

(no significant difference). After 1 year, volumes were 5.5 ± 11.7 mL versus

16.4 ± 13.7 mL (P<0.001), with a median 85.6% versus 7.3% reduction,

respectively (P<0.001), of the initial volume. The median nodule volume

reduction after PEI was 88.8% and 65.8% in empty body and mixed

thyroid cysts, respectively. Compressive and cosmetic symptoms disappeared

in 74.8% and 80.0% of patients treated with PEI versus 24.4% and 37.4%

of patients treated with simple evacuation, respectively (P<0.001). Side

effects were minor.

Conclusion: These data provide definitive evidence that PEI is a safe

and effective treatment for thyroid cystic nodules. Unicameral thyroid

cysts are the most suitable candidate nodules for PEI. (Endocr Pract.


Percutaneous ethanol injection therapy in the treatment of

thyroid and parathyroid diseases

Relevant English language articles published from 1966 to 1995

regarding ethanol therapy in the treatment of thyroid and

parathyroid diseases were identified through a MEDLINE search

and manual searches of identified articles.

The sclerosing properties of ethanol have been recognized

for many years and have offered interventional possibilities

in the management of various benign as well as malignant lesions.

The mechanism of action of ethanol appears to be related to a

direct coagulative necrosis and local partial or complete small

vessel thrombosis. Ultrasound-guided percutaneous ethanol

injection therapy (PEIT) is rapid and performed on an out-patient

basis and has now gained wide acceptance due to the accumulating

evidence of the efficacy and safety of this therapeutic tool. Yet,

here is a lack of prospective, randomized clinical trials comparing

PEIT with 131I therapy or surgery with regard to its effects, especially

long-term ones and it should therefore still be considered an experimental


In benign endocrine diseases, PEIT has shown promising results

in the treatment of autonomous thyroid nodules, benign solitary

cold solid as well as cystic thyroid nodules and parathyroid tumours.

Its use in pretoxic and toxic thyroid nodules has been evaluated in

several uncontrolled studies, all demonstrating a high success rate

in spite of the large number of treatments needed. So far efficacy and

cost-effectiveness seem inferior to 131I and surgery. Short-term results

of PEIT in benign cystic thyroid nodules are convincing with a high cure

rate, but no controlled studies with long-term results are available.

Preliminary results suggest that PEIT could become an alternative

to surgical excision or levothyroxine therapy in the symptomatic solid

cold benign thyroid nodule.

Ultrasound-guided PEIT of parathyroid tumours has proven to be a

useful method in highly selected patients in whom surgery has been

found non-attractive and medical treatment ineffective. However, no

prospective randomized trials have been published comparing the

results of PEIT in parathyroid tumours with conventional surgical and

medical treatments.

PEIT has never been tested against standard therapy, but seems

inferior to 131I and surgery. Side-effects caused by ethanol injection

are generally few and transient and are related to the injection into

solid nodules rather than cysts. Ethanol injection into solid profund

nodules may seriously jeopardize subsequent surgery because of

perinodular fibrosis. As an experimental procedure, not yet evaluated

sufficiently, it should be reserved for patients who cannot or will not

undergo standard therapy. Caution in routine use is advisable.

thyroid surgical alternative ethanol

ethanol mixed cyst ablation ( PEI )


To compare the efficacy of ethanol ablation (EA) of cystic and predominantly cystic thyroid nodules, and to evaluate factors affecting efficacy.


From October 2008 to December 2010, a total of 217 thyroid nodules were treated with EA. Nodule volumes, symptoms and cosmetic scores were evaluated before and after EA. EA efficacy in treating cystic and predominantly cystic nodules was compared; and factors related to EA efficacy in each type, including initial volume, solid component, vascularity, fluid nature, ethanol retention time and number of EA sessions, were evaluated.


Mean nodule volume decreased from 15.7 ± 18.1 ml to 3.0 ± 7.9 ml (mean volume reduction, 85.2 ± 16.1%) and the therapeutic success rate was 90.3% at last follow-up. EA was significantly more effective in cystic than predominantly cystic nodules. Independent predictors of EA efficacy for all nodules included initial volume, solid component and vascularity. Initial volume and vascularity were independent predictors of EA efficacy in predominantly cystic nodules, but no factor was independently related to efficacy in cystic nodules.


EA is effective in both cystic and predominantly cystic nodules, especially the former. EA is less effective in large or vascular predominantly cystic nodules, but is effective in cystic nodules regardless of related factors.

Key Points

• Ethanol ablation under ultrasound guidance is increasingly used for cystic thyroid nodules.

• EA seems effective for cystic and predominantly cystic nodules, especially cystic nodules.

• The effectiveness of EA was reduced in large or vascular predominantly cystic nodules.

radiofrequency thyroid nodule ablation (RFA)

This study evaluated the safety and volume reduction of ultrasonography (US)-guided radiofrequency ablation (RFA) for benign thyroid nodules, and the factors affecting the results obtained. A total of 302 benign thyroid nodules in 236 euthyroid patients underwent RFA between June 2002 and January 2005. RFA was carried out using an internally cooled electrode under local anesthesia. The volume-reduction ratio (VRR) was assessed by US and safety was determined by observing the complications during the follow-up period (1–41 months). The correlation between the VRR and several factors (patient age, volume and composition of the index nodule) was evaluated. The volume of index nodules was 0.11–95.61 ml (mean, 6.13 ± 9.59 ml). After ablation, the volume of index nodules decreased to 0.00–26.07 ml (mean, 1.12 ± 2.92 ml) and the VRR was 12.52–100% (mean, 84.11 ± 14.93%) at the last follow-up. A VRR greater than 50% was observed in 91.06% of nodules, and 27.81% of index nodules disappeared. The complications encountered were pain, hematoma and transient voice changes. In conclusion, RFA is a safe modality effective at reducing volume in benign thyroid nodules.

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